arthyperАртериальная гипертензия"Arterial’naya Gipertenziya" ("Arterial Hypertension")1607-419X2411-8524Antihypertensive League10.18705/1607-419X-2015-21-2-190-196arthyper-212Research ArticleЛЕКЦИЯLECTUREЛечение больного артериальной гипертензией высокого риска: нужна ли антиагрегантная терапия?Treatment of patient with high-risk hypertension: do we need antiplatelet therapy?МинушкинаЛ. О.MinushkinaL. O.

профессор кафедры терапии, кардиологии и функциональной диагностики ФГБУ «Учебно-научный медицинский центр» УД Президента РФ; 

MD, PhD, Professor, Department of Internal Medicine, Cardiology and Functional Diagnostic with Nephrology Course, Federal State Institution «Educational Scientific Medical Center» of the Administrative Office of the President of Russian Federation; 

minushkina@mail.ruСавинаН. М.SavinaN. M.

доцент кафедры терапии, кардиологии и функциональной диагностики ФГБУ «Учебно-научный медицинский центр» УД Президента РФ

MD, PhD, Associate Professor, Department of Internal Medicine, Cardiology and Functional Diagnostic with Nephrology Course, Federal State Institution «Educational Scientific Medical Center» of the Administrative Office of the President of Russian Federation.

Федеральное государственное бюджетное учреждение «Учебно-научный медицинский центр» Управления делами Президента Российской Федерации, Москва, РоссияРоссияFederal State Institution «Educational Scientific Medical Center» of the Administrative office of the President of Russian Federation, Moscow, RussiaRussian Federation201516072015212190196Copyright © Минушкина Л.О., Савина Н.М., 20152015Минушкина Л.О., Савина Н.М.Minushkina L.O., Savina N.M.This work is licensed under a Creative Commons Attribution 4.0 License.https://htn.almazovcentre.ru/jour/article/view/212

В настоящем обзоре представлены данные о проблемах назначения ацетилсалициловой кислоты (АСК) в широкой клинической практике. Наиболее спорным является вопрос о назначении антитромбоцитарных препаратов с целью первичной профилактики сердечно-сосудистых осложнений. Имеющиеся клинические рекомендации в отношении необходимости назначения препаратов АСК противоречивы. Показано, что это наиболее часто назначаемый в рутинной практике антитромбоцитарный препарат. Частота применения его растет. Приведены данные клинических исследований и основных метаанализов об эффективности и безопасности назначения АСК у пациентов с артериальной гипертензией (АГ), сахарным диабетом (СД), при нарушении функции почек, а также различия эффективности в зависимости от пола и возраста больных. Рассмотрены дополнительные критерии высокого риска сердечно-сосудистых осложнений, а также основные клинические рекомендации, касающиеся возможностей назначения АСК у больных АГ и СД. Широкое применение АСК особенно актуализирует задачу оценки риска осложнений антитромбоцитарной терапии и поиск возможных путей их профилактики. Приведены данные об основных группах риска развития желудочно-кишечных кровотечений. Описаны основные профилактические подходы, касающиеся назначения различных лекарственных форм АСК, дополнительной терапии блокаторами секреции, проведения эрадикационной терапии. 

This review summarizes the main problems of acetylsalicylic acid (ASA) use in clinical practice. The prescription of antiplatelet therapy for primary cardiovascular prevention is the most controversial. The available clinical guidelines are contradictory. Antiplatelet drugs are the most commonly prescribed medication in routine practice, and the rates are growing. The article reviews the data of clinical trials and basic meta-analysis on the effectiveness and safety of ASA in patients with hypertension (HTN), diabetes mellitus (DM), renal dysfunction, as well as age- and gender-associated differences. Additional criteria are considered in high-risk patients. A special attention is paid to the main clinical recommendations regarding the use of ASA in patients with HTN and DM. Common use of ASA increases the risk of complications and requires the search for possible preventive approaches. Thus, the main risk groups for gastrointestinal bleeding are listed. Moreover, the main preventive approaches regarding the various forms of ASA, the use of adjunctive therapy by secretion blockers and eradication therapy are discussed. 

первичная профилактикаацетилсалициловая кислотажелудочно-кишечные кровотеченияprimary preventionacetylsalicylic acidgastrointestinal hemorrhageReferencesMontalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.Steg PG, James SK, Atar D, Badano LP, Badano LP, Blömstrom-Lundqvist C, Borger MA et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33 (20):2569–2619.Steg PG, James SK, Atar D, Badano LP, Badano LP, Blömstrom-Lundqvist C, Borger MA et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33 (20):2569–2619.Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H et al. European Society of Cardiology. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. G Ital Cardiol (Rome). 2012;13(3):171–228.Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H et al. European Society of Cardiology. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. G Ital Cardiol (Rome). 2012;13(3):171–228.Andrus B, Lacaille D. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2014;63 (2):2886.Andrus B, Lacaille D. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2014;63 (2):2886.Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelinesю Chest. 2012;141(2): e637S-e668S.Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelinesю Chest. 2012;141(2): e637S-e668S.Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren WM et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J. 2012;33(13):1635–1701.Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren WM et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J. 2012;33(13):1635–1701.Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology. 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press. 2014;23(1):3–16.Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology. 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press. 2014;23(1):3–16.Ryden L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N et al. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD — summary. Diab Vasc Dis Res. 2014;11(3):133–173.Ryden L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N et al. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD — summary. Diab Vasc Dis Res. 2014;11(3):133–173.Jaques H. National Institute for Health and Clinical Excellence (NICE). NICE guideline on hypertension. Eur Heart J. 2013;34(6):406–8.Jaques H. National Institute for Health and Clinical Excellence (NICE). NICE guideline on hypertension. Eur Heart J. 2013;34(6):406–8.Seshasai SR, Wijesurjya S, Sivakumaran R, Nethercott S, Ergou S, Sattar N, Ray KK. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(3):209–16.Seshasai SR, Wijesurjya S, Sivakumaran R, Nethercott S, Ergou S, Sattar N, Ray KK. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(3):209–16.Sutcliffe P, Connock M, Gurung T. Aspirin for prophylactic use in the primary prevention of cardiovascular disease and cancer: a systematic review and overview of reviews Health Technology Assessment. 2013;17(43):2–4.Sutcliffe P, Connock M, Gurung T. Aspirin for prophylactic use in the primary prevention of cardiovascular disease and cancer: a systematic review and overview of reviews Health Technology Assessment. 2013;17(43):2–4.Berger JS, Lala A, Krantz MJ, Baker GS, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: a meta-analysis of randomized trials. Am Heart J. 2011;162(1):115–24.Berger JS, Lala A, Krantz MJ, Baker GS, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: a meta-analysis of randomized trials. Am Heart J. 2011;162(1):115–24.Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373 (9678):1849–60.Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373 (9678):1849–60.Ikeda Y, Shimada K, Teramoto T, Uchiyama S, Yamazaki T, Oikawa S et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: a randomized clinical trial. J Am Med Assoc. 2014;312(23):2510–2520.Ikeda Y, Shimada K, Teramoto T, Uchiyama S, Yamazaki T, Oikawa S et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: a randomized clinical trial. J Am Med Assoc. 2014;312(23):2510–2520.Zanchetti A, Hansson L, Dahlof B. Benefit and harm of low-dose aspirin in well-treated hypertensives at different baseline cardiovascular risk. J Hypertens. 2002;20(11):2301–2307.Zanchetti A, Hansson L, Dahlof B. Benefit and harm of low-dose aspirin in well-treated hypertensives at different baseline cardiovascular risk. J Hypertens. 2002;20(11):2301–2307.Jardine MJ, Ninomiya T, Perkovic V, Cass A, Turnbull F, Gallagher MP et al. Aspirin is beneficial in hypertensive patients with chronic kidney disease: a post-hoc subgroup analysis of a randomized controlled trial. J Am Coll Cardiol. 2010;56 (12):956–965.Jardine MJ, Ninomiya T, Perkovic V, Cass A, Turnbull F, Gallagher MP et al. Aspirin is beneficial in hypertensive patients with chronic kidney disease: a post-hoc subgroup analysis of a randomized controlled trial. J Am Coll Cardiol. 2010;56 (12):956–965.Fossum E, Dahlof B, Kjeldsen SE, Devereux RB, Julius S, Snapinn SM. The interaction between aspirin and losartan on cardiovascular morbidity and mortality in patients with hypertension and left ventricular hypertrophy. a losartan intervention for endpoint reduction (LIFE) substudy. J Hypertens. 2003;21(4): S118.Fossum E, Dahlof B, Kjeldsen SE, Devereux RB, Julius S, Snapinn SM. The interaction between aspirin and losartan on cardiovascular morbidity and mortality in patients with hypertension and left ventricular hypertrophy. a losartan intervention for endpoint reduction (LIFE) substudy. J Hypertens. 2003;21(4): S118.Miedema MD, Duprez DA, Misialek JR Blaha MJ, Nasir K, Silverman MG et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multiethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7(3):453–460.Miedema MD, Duprez DA, Misialek JR Blaha MJ, Nasir K, Silverman MG et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multiethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7(3):453–460.Okada S, Morimoto T, Ogawa H, Sakuma M, Soejima H, Nakayama M et al. Effect of low-dose aspirin on primary prevention of cardiovascular events in Japanese diabetic patients at high risk. Circ J 2013;77(12):3023–3028.Okada S, Morimoto T, Ogawa H, Sakuma M, Soejima H, Nakayama M et al. Effect of low-dose aspirin on primary prevention of cardiovascular events in Japanese diabetic patients at high risk. Circ J 2013;77(12):3023–3028.Soejima H, Ogawa H, Morimoto T, Nakayama M, Okada S, Sakuma M et al. Aspirin possibly reduces cerebrovascular events in type 2 diabetic patients with higher C-reactive protein level: subanalysis from the JPAD trial. J Cardiol. 2013;62(3):165–170.Soejima H, Ogawa H, Morimoto T, Nakayama M, Okada S, Sakuma M et al. Aspirin possibly reduces cerebrovascular events in type 2 diabetic patients with higher C-reactive protein level: subanalysis from the JPAD trial. J Cardiol. 2013;62(3):165–170.American Diabetes Association. Standards of medical care in diabetes — 2014. Diabetes Care. 2014;37(1): S14-S80.American Diabetes Association. Standards of medical care in diabetes — 2014. Diabetes Care. 2014;37(1): S14-S80.Kolber M, Sharif N, Marceau R, Szafran O. Family practice patients’ use of acetylsalicylic acid for cardiovascular disease prevention Can Fam Physician. 2013;59:55–61.Kolber M, Sharif N, Marceau R, Szafran O. Family practice patients’ use of acetylsalicylic acid for cardiovascular disease prevention Can Fam Physician. 2013;59:55–61.Hissett J, Folks B, Coombs L, Leblanc W, Pace WD. Effects of changing guidelines on prescribing aspirin for primary prevention of cardiovascular events. J Am Board Fam Med. 2014;27(1):78–86.Hissett J, Folks B, Coombs L, Leblanc W, Pace WD. Effects of changing guidelines on prescribing aspirin for primary prevention of cardiovascular events. J Am Board Fam Med. 2014;27(1):78–86.Fiscella K, Winters PC, Mendoza M, Noronha GJ, Swanger CM, Bisognano JD et al. Do clinicians recommend aspirin to patients for primary prevention of cardiovascular disease? J Gen Intern Med. 2015;30(2):155–160.Fiscella K, Winters PC, Mendoza M, Noronha GJ, Swanger CM, Bisognano JD et al. Do clinicians recommend aspirin to patients for primary prevention of cardiovascular disease? J Gen Intern Med. 2015;30(2):155–160.Mainous AG, Tanner RJ, Shorr RI, Limacher MC. Use of aspirin for primary and secondary cardiovascular disease prevention in the United States, 2011–2012. J Am Heart Assoc. 2014;3 (4). pii: e000989. doi: 10.1161/JAHA.114.000989.Mainous AG, Tanner RJ, Shorr RI, Limacher MC. Use of aspirin for primary and secondary cardiovascular disease prevention in the United States, 2011–2012. J Am Heart Assoc. 2014;3 (4). pii: e000989. doi: 10.1161/JAHA.114.000989.Weil J, Colin-Jones D, Langman M, Lawson D, Logan R, Murphy M et al. Prophylactic aspirin and risk of peptic ulcer bleeding. Br Med J. 1995;310(6983):827–30.Weil J, Colin-Jones D, Langman M, Lawson D, Logan R, Murphy M et al. Prophylactic aspirin and risk of peptic ulcer bleeding. Br Med J. 1995;310(6983):827–30.Nonsteroidal anti-inflammatory drugs: add an anti-ulcer drug for patients at high risk only. Always limit the dose and duration of treatment with NSAIDs. Prescrire Int. 2011;20(119):216–219.Nonsteroidal anti-inflammatory drugs: add an anti-ulcer drug for patients at high risk only. Always limit the dose and duration of treatment with NSAIDs. Prescrire Int. 2011;20(119):216–219.Chan FK, CHing JY, Hung LC, Wong VW, Leung VK, Kung NN et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352 (3):238–244.Chan FK, CHing JY, Hung LC, Wong VW, Leung VK, Kung NN et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352 (3):238–244.Lai KC, Chu KM, Hui WM, Wong BC, Hung WK, Loo CK et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroenterol Hepatol. 2006;4(7):860–865.Lai KC, Chu KM, Hui WM, Wong BC, Hung WK, Loo CK et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroenterol Hepatol. 2006;4(7):860–865.Tsai TJ, Lai KH, Hsu PI, Hsu PI, Tsai WL, Tsai TJ et al. Upper gastrointestinal lesions in patients receiving clopidogrel antiplatelet therapy. J Formos Med Assoc. 2012;111(12):705–710.Tsai TJ, Lai KH, Hsu PI, Hsu PI, Tsai WL, Tsai TJ et al. Upper gastrointestinal lesions in patients receiving clopidogrel antiplatelet therapy. J Formos Med Assoc. 2012;111(12):705–710.Takada M, Fujimoto M, Hosomi K. Difference in risk of gastrointestinal complications between users of enteric-coated and buffered low-dose aspirin. Int J Clin Pharmacol Ther. 2014;52 (3):181–91.Takada M, Fujimoto M, Hosomi K. Difference in risk of gastrointestinal complications between users of enteric-coated and buffered low-dose aspirin. Int J Clin Pharmacol Ther. 2014;52 (3):181–91.Баркаган З. С., Котовщикова Е. Ф. Сравнительный анализ основных и побочных эффектов различных форм ацетилсалициловой кислоты. Клиническая фармакология и терапия. 2004;13(3):40–43. [Barkagan ZS, Kotovshchikova EF. Comparative analysis of the main and side effects of different forms of acetylsalicylic acid. Clinicheskaya Farmakologiya i Terapiya = Clinical Pharmacology and Therapeutics. 2004;13 (3):40–43. In Russian].Баркаган З. С., Котовщикова Е. Ф. Сравнительный анализ основных и побочных эффектов различных форм ацетилсалициловой кислоты. Клиническая фармакология и терапия. 2004;13(3):40–43. [Barkagan ZS, Kotovshchikova EF. Comparative analysis of the main and side effects of different forms of acetylsalicylic acid. Clinicheskaya Farmakologiya i Terapiya = Clinical Pharmacology and Therapeutics. 2004;13 (3):40–43. In Russian].Яковенко Э. П., Краснолобова Л. П., Яковенко А. В., Агафонова Н. А., Иванов А. Н., Богомолова Е. А. и др. Влияние препаратов АСК на морфофункциональное состояние слизистой оболочки желудка у кардиологических пациентов пожилого возраста. Сердце: журнал для практикующих врачей. 2013;12(3):145–150. [Yakovenko EP, Krasnolobova LP, Yakovenko AV, Agafonova NA, Ivanov AN, Bogomolova EA et al. Influence of drugs on the ASA morphofunctional state of gastric mucosa in cardiac patients elderly. Heart: the magazine for practicing physicians. 2013;12(3):145–150. In Russian].Яковенко Э. П., Краснолобова Л. П., Яковенко А. В., Агафонова Н. А., Иванов А. Н., Богомолова Е. А. и др. Влияние препаратов АСК на морфофункциональное состояние слизистой оболочки желудка у кардиологических пациентов пожилого возраста. Сердце: журнал для практикующих врачей. 2013;12(3):145–150. [Yakovenko EP, Krasnolobova LP, Yakovenko AV, Agafonova NA, Ivanov AN, Bogomolova EA et al. Influence of drugs on the ASA morphofunctional state of gastric mucosa in cardiac patients elderly. Heart: the magazine for practicing physicians. 2013;12(3):145–150. In Russian].

The authors declare that there are no conflicts of interest present.